Exploring Pain Pain, while unpleasant, is a crucial component of our survival. Without pain, we would have no motivation to escape or avoid things which cause injury, so that our bodies can function at their best, unharmed. However, it is not always the case that if you feel pain, it must be because there is something physically harming your body. The reality is that the relationship between a noxious stimulus (something that causes tissue damage) and the sensation of pain is not so straight-forward. Several studies have been conducted to support this… In a study conducted in 2010, all participants were inflicted with the same painful stimulus. Half the participants were told that the study hadn’t received ethical approval (don’t worry – it had!), and these participants systematically reported experiencing more pain than those who believed that the study was ethical. This is because those participants who believed the study was unethical expected a greater threat, despite both groups receiving the same stimulus (Wiech et al, 2010). In another study in 2009, both groups were given a cream before being inflicted with pain. One group was told that the cream numbed their skin, and (you guessed it!) those who didn’t have this placebo belief reported experiencing more pain than those with the fake anesthetic (Eippert et al 2009). So, clearly, there is more going on with our response to noxious stimuli than simply the effect that is has on our tissues. Instead, we can start to see how the signals communicating our pain can be impacted by other factors, including our expectations and belief about the pain, and even what mood we’re in (Loggia et al, 2008). The relationship between Nociceptive, Neuropathic and Chronic pain The sensation of pain associated with tissue damage is known as ‘nociceptive pain’. However, sometimes there is still pain even after the tissue damage has healed. This is because the neurons responsible for signaling pain can become damaged in some way, so that they keep firing even in the absence of noxious stimuli. This is known as ‘neuropathic pain’. Chronic Pain is defined as pain that lasts longer than three months. Sometimes, Chronic Pain is initially nociceptive, caused by another condition or injury that a patient might have which has harmed the body. However, when the pain persists even after the injury has healed or condition has gone away, as is often the case with Chronic Pain, it is likely to be neuropathic. This kind of pain experienced for such an extended amount of time can have a devastating impact on sufferers’ lives: “From being fiercely independent and athletic my entire life to not being able to carry a cup of tea from the kitchen to the living room, much less carry shopping home from the supermarket. I was lost to myself.” (Patient with Chronic Pain, 2023) A strain on the HCP-patient relationship When someone says that they have experienced a lot of pain for a long time, their doctor’s initial goal will be to identify the tissue damage that they assume is causing the symptom of pain. But when pain is neuropathic, it can appear as though there is nothing ‘wrong’ physically, and therefore there is nothing to ‘fix’. This causes a lot of frustration for doctors and those experiencing chronic pain alike. Since the perception of pain is subjective and therefore difficult to measure, many doctors grow skeptical about their patient’s pain, which in turn leaves sufferers feeling as though their pain is not taken seriously by their doctors. “Some people say ‘This is the worst pain I’ve had in my whole life’ without any real sort of physical signs of pain, it’s really tough; we have a complex job in assessing that” (HCP, 2010) (Toye et al, 2017) When patients feel as though they are not being heard by skeptical doctors, this can have enormous consequences on their mental health and general quality of life. As well as continuing to experience the pain, they are left feeling hopeless and isolated, mourning the capabilities they had before the pain began. Those experiencing more persistent chronic pain often go through years and years of referrals and rejections from HCPs who dismiss their experience, delaying the patient from receiving treatment that they need to manage their pain, and allowing for further deterioration of mental wellbeing. “I was in a really dark place for such a long time, and none of the people supposed to be charged with my care, my well-being, appeared to even notice that side of things, much less care. And that is something they could have helped with.” (Patient with Chronic Pain, 2023) Managing Chronic Pain The blanket advice that doctors often give to patients reporting pain is to take ‘over-the-counter’ (OTC) medication (e.g., paracetamol or NSAIDs). However, these are often ineffective for Chronic Pain, and can have a host of negative side effects if used long-term (e.g., GI tract issues). Once a specialist does recognize and diagnose pain as chronic, they might consider pharmacological therapies that are better suited for management of long-term neuropathic pain. A class of drugs known as Gabapentinoids, such as Gabapentin and Pregabalin, work by stabilising the nervous system (and are therefore used to treat other conditions such as epilepsy and anxiety), which help to minimise unpredictable flare-ups of pain. However, Gapapentinoids can cause drowsiness, making some activities such as driving a car unsafe – between the high frequency dosage and common side effects, these oral medications can be quite disruptive to the lifestyles of those with Chronic Pain. It is up to the doctor and the patient to weigh up the risks and benefits of treatment to find the best way to manage Chronic Pain. Another option which pain specialists can prescribe are Lidocaine patches, which are a type of local anaesthetic that numbs the painful area that the patch is applied to. However, the relief provided by these patches is only temporary as wearing them for too long can result in serious side effects. Individuals suffering from Chronic Pain often need to use a combination of pills and patches to manage their pain, and even then it can’t be relieved completely. “There is no medication that will get rid of my pain completely…It is really difficult to come to terms with the thought of living with pain and keep a sense of purpose” (Patient with Chronic Pain, 2015) (Toye et al, 2017) What may come as a surprise is that for those suffering with Chronic Pain the real gamechanger is not the drugs that they can be eventually prescribed, but the psychosocial therapies that they can be referred on to. These programmes work by helping the individual to reframe their perception of their pain, allowing them to cope with it and perceive it to place less of a burden on their life. While the misconception that all pain must have a physical cause makes many sufferers skeptical of this approach, psychosocial therapies have had a lot of success in improving quality of life of those living with Chronic Pain (Cochran, 2020). However, despite clear need, these life-changing psychosocial pain management programmes are few and far between, and the waitlists can be years long, once again increasing opportunity for Chronic Pain to escalate and mental wellbeing to decline. What’s more, the internalized stigma surrounding Chronic Pain, entrenched by a society in which we have a nociceptive understanding of pain, provides a huge barrier for sufferers (and their doctors!) appreciating the efficacy of psychosocial approaches. The future of Chronic Pain needs to be brighter Despite being such a common condition, the stigma associated with neuropathic and chronic pain means that there’s not a lot of clinical innovation in this area. There is certainly room for exploration of more long-acting and efficacious pharmacological therapies, which do not add even more limitations to patients’ lifestyle and capabilities. What’s more, there is a clear demand for increased access to psychosocial pain management programmes, which have demonstrated the capacity to change the lives of those suffering from Chronic Pain, even if they can’t make the pain fully go away. The bottom line is, there is a grave misconception that pain is only valid if there are physical signs of it, and this isn’t helped by doctors. The first step towards brightening the future of Chronic Pain is to work to educate doctors and members of society alike to understand pain, and that someone doesn’t need an obvious physical symptom in order to experience it. Then, doctors need to shift their focus away from treating an ‘unfixable’ condition, and towards supporting patients towards foreseeing an enriched life despite their pain. Look out for our next blog on Chronic Pain, which will dive into one individual’s story, from initial life-changing injury, to the clinical mistakes and dismissals which over many years aggravated both the pain and mental anguish, all the way through to acceptance of a life unlimited by Chronic Pain. By Millie Morgan Sources https://painconcern.org.uk/product/gabapentin-and-pregabalin/ Toye, F., Seers, K., Hannink, E., & Barker, K. (2017). A mega-ethnography of eleven qualitative evidence syntheses exploring the experience of living with chronic non-malignant pain. BMC medical research methodology, 17(1), 1-11 Wiech, K., Lin, C. S., Brodersen, K. H., Bingel, U., Ploner, M., & Tracey, I. (2010). Anterior insula integrates information about salience into perceptual decisions about pain. Journal of Neuroscience, 30(48), 16324-16331. Eippert, F., Bingel, U., Schoell, E. D., Yacubian, J., Klinger, R., Lorenz, J., & Büchel, C. (2009). Activation of the opioidergic descending pain control system underlies placebo analgesia. Neuron, 63(4), 533-543 https://www.cochrane.org/news/featured-review-psychological-therapies-management-chronic-pain-excluding-headache-adults https://www.panmerseyapc.nhs.uk/media/2131/opioidsgabapentinoids.pdf Loggia, M. L., Mogil, J. S., & Bushnell, M. C. (2008). Experimentally induced mood changes preferentially affect pain unpleasantness. The Journal of Pain, 9(9), 784-791. Toye, F., Seers, K., & Barker, K. L. (2017). Meta-ethnography to understand healthcare professionals’ experience of treating adults with chronic non-malignant pain. BMJ open, 7(12), e018411 Apply Now!